New focus on Top End doctors’ health

Practising medicine in the Northern Territory can be as rewarding as anywhere else, but it has its own particular challenges. Many NT doctors work in remote and isolated regions where they have to be able to rely on themselves, without the kind of support they’d find in the capital cities.

Until recently, there were very limited health services for NT doctors and no dedicated support network. But in 2016, a group of Adelaide-based health professionals stepped into the breach and set up Doctor’s Health NT, which offers a 24-hour advisory helpline, telemedicine and a network of local GPs trained to see doctors and medical students as patients.

“The NT medical community is small, with only about 1000 doctors,” says Adelaide-based GP Dr Roger Sexton, who as director of Doctors’ Health SA was instrumental in setting up the NT satellite.

“There are interesting challenges in doing medicine out there. There’s a wide range of workplaces, from aboriginal communities to work out on the islands or in remote communities, and doctors are expected to be well-rounded and pretty self-reliant. But when it comes to their own health, one solution doesn’t always work for all doctors.”

Dr Sexton says it’s easy for NT doctors to get isolated because they personally know most of the other doctors in the Territory, which means they can’t easily get treated anonymously.

“A lot of the doctors find the convenience of self-treatment too easy. If you’re a dermatologist in Melbourne, you’ve got a very good choice of who you can see. But in the NT the options are limited. Many doctors have concerns about confidentiality, and there’s always the issue of notification sitting in the background.

“When they do seek help, they often do it selectively. They’ll see a GP for some issues but not for mental health. Often they practice a form of blended care where they do a bit of self-investigation, self-prescribing and self-referral.”

Doctors’ Health NT has a 24-hour helpline, but Dr Sexton says the penetration is pretty low, which means things have to be done a little differently.

“We’re running a trial for GP teleconsults, which gives doctors the chance to consult with a doctor who is not necessarily part of their personal network. We’ve had very strong support for that model: it’s a great way for an initial talk about an issue and some follow-up.”

He says telemedicine is an excellent way to break down isolation, particularly for doctors who pride themselves on being tough and are reluctant to admit they’re struggling.

But Doctors’ Health NT has also established a network of GPs on the ground who are trained to treat other doctors and medical students.

“We’re trying to grow that network. We have ten GPs at the moment which we hope to expand to 30.”

Dr Sexton says having a GP-centric model for doctors’ health is critical because it can address both physical and mental health issues.

“With a psychiatrist-based model you miss out on all the physical stuff, which can be very important. GPs are also a non-stigmatising way of getting a foot in the door. You can say to doctors that the approach is physical, and along the way we’ll be asking you about your life as a doctor.”

You can access the services of Doctors’ Health NT here.

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Mandatory reporting: the “low hanging fruit” in doctors’ health

Mandatory reporting came under fire at a panel discussion on doctors’ health at the AMA National Conference held in Melbourne late last month.

Currently all states, with the exception of Western Australia, have regulations which require health practitioners to report colleagues who they feel may be a threat to their patients to AHPRA or the Medical Board of Australia.

Although mandatory reporting requirements are well-intentioned efforts to protect patients, many professionals worry they are a major barrier to doctors seeking help for their mental health issues.

Speaking on the panel, Dr Bav Manoharan, a Queensland-based radiology registrar who has been involved in resilience building projects, said there was confusion around mandatory reporting legislation and what the threshold was for reporting colleagues to AHPRA.

“That is a real concern,” he said. “There’s a stigma around a doctor approaching a health service and asking for help in environments where there is mandatory reporting.”

He said that changes to manadatory reporting requirements and a clearer understanding of them were the “low-hanging fruit” in the debate around doctors’ health.

Dr Janette Randall, a Queensland-based GP who is chair of Doctors Health Services Pty Ltd, noted that the threshold for reporting was actually quite high but there was a lot of subjectivity and doctors were getting inappropriately reported.

“We have a strong sense of fear and reluctance to present for care and this is one of the barriers. I do think the time has come to remove the onus on treating practitioners to report. That’s not to say we don’t all retain an ethical and professional responsibility in that space, but we’ve got to be able to create safe environments for people to seek care.”

Marie Jepson, who has been involved in research into depression in the legal community, said mandatory reporting tended to drive mental health issues underground.

“We found there were lawyers who would deliberately not go to the doctor, even though they were quite ill, so they didn’t have to lie on their application for a practising certificate. It meant that they complied with the regulation, but it was a timebomb waiting to go off.”

The issue of revamping mandatory reporting requirements does seem to be gaining traction, particularly in New South Wales, where Health Minister Brad Hazzard has announced he will review the legislation.

Mr Hazzard met with health stakeholders at a forum this week in Sydney to discuss measures to improve the mental health of doctors, after several high profile cases of doctor suicides in the state.

“It’s really critical for people with mental health issues to be able to talk to someone with absolute confidence and know that person is there to help and not to judge them – that’s the critical problem with mandatory reporting,” Mr Hazzard told the forum.

“Having listened to the young doctors it may be that the mandatory reporting requirements are technically not the problem, but practically they are, because that perception among young doctors is by seeking mental health help they may be damaging their career. It looks to me that mandatory reporting provisions do need changing.”

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Work-readiness and workforce numbers: the challenges

We need clinicians prepared for work in a system of integrated, person-centred, affordable health care

Over the past 15 years or so, Australia has embarked upon what some might describe as a “courageous” solution for guaranteeing our medical workforce. Following a perceived shortage of doctors at the beginning of the 2000s, the number of accredited medical schools has grown from 10 to 20,1 with another currently undergoing accreditation; the number of medical graduates has almost tripled from 1316 in 2001 to 3547 in 2015.2 Increasingly large numbers of doctors have also been recruited from overseas to overcome shortfalls: 2820 temporary visas were granted during 2014–15 alone.3 The per capita production of local medical graduates4 and growth in the stock of foreign-trained doctors5 are among the highest in the world.

Australia is also a leader in more sensible ways: establishing rural clinical schools and regional medical schools and increasing the numbers of rural origin and Indigenous Australian medical students. Clinical training for students has spread well beyond the traditional metropolitan teaching hospital. Rural sites are at the cutting edge of reforms, including community-engaged medical education, longer, integrated clinical placements, and inter-professional learning, resulting in some solid workforce outcomes.6–8 The high levels of graduation and importation over 15 years have markedly increased doctor numbers. With 3.5 practising doctors per 1000 population (2014), Australia has more doctors per capita than Canada (2.6), the United States (2.6), New Zealand (2.8) or the United Kingdom (2.8), and exceeds the OECD average of 3.3 doctors per 1000.4

There is accordingly no overall shortage of doctors in 2017. But a regional hospital attempting to recruit an Australian-trained surgeon or psychiatrist, or a remote community looking for a broadly skilled rural generalist practitioner might beg to differ. Regional Australia remains heavily reliant on the provisional solution of importing medical labour, while growing numbers of domestic graduates jostle for internships and specialist training positions in the cities, swelling the ranks of an increasingly subspecialised metropolitan workforce. Joining them are many international recruits who move to cities after their obligatory period of service in rural areas is completed.

Factors that promote this situation include uncapped fee-for-service insurance systems, high volume corporate practice models, and the staffing and rostering proclivities of large hospitals. Threats to the system associated with the high number of city doctors include higher levels of inappropriate care servicing, fragmentation of care, yet more constraint on the scope of generalist clinical practice, and fiscal pain for taxpayers.

Increasing the number of medical graduates as a solution for workforce shortfalls has faltered because the job was only half done. Medical school, while important in itself, is the stepping-off point for further training: the first year as an intern, and then (after a period as a junior hospital doctor) years of training towards a fellowship in general practice or one of the 63 other recognised medical specialties. Australia has the second highest number of stand-alone specialty fellowships, after the US.9

As long as the funding, physical and cultural base for internship and subsequent training remains centred on big metropolitan hospitals and city practices, there be will no home-grown solution for securing our medical workforce. Even rurally inclined graduates who have trained in rural areas may feel obliged to join the race for city training positions,6 which typically means years in a metropolitan training pathway. Meanwhile, life events intervene and become barriers to returning to rural communities.

These bottlenecks in clinical training are occurring at a time when responsibility for its support is unclear, given our regionally autonomous public hospital system, funded according to clinical activity.10 With no transparent funding model for teaching and training, historical practices more or less prevail. Opportunities for interns, junior doctors and specialist trainees to train in private or non-government organisational settings remain limited.

What does all this mean for the work-readiness of an intern, or indeed of medical graduates at any point along the medical training continuum, including career-long learning?

One view of work-readiness is that provided by surveys of graduates’ own assessment of their preparedness for work as an intern in a large hospital, as described by Barr and her colleagues in this issue of the MJA.11 Their study found that the graduates surveyed generally felt well prepared with respect to 44 specific capabilities, including patient-centred care, although there was also a small number for which they did not feel well prepared, such as providing nutritional care, using informatics, and cultural competency.

These findings raises the question of the utility of the medical internship model, a problem discussed in a 2015 Council of Australian Governments review, which concluded that the model was still of value, but could be improved to better achieve its goals.12 For instance, although outcome statements for medical graduates and interns are a helpful guide for medical graduates and their supervisors, there is room for improving dialogue between universities and employers about work-readiness.

However, we believe there is a broader perspective from which to judge work-readiness: whether the training system (including internship) is producing sufficient numbers of clinicians ready for work that is aligned with community needs for integrated, person-centred, affordable health services for an ageing population that is experiencing higher levels of chronic disease.

To achieve this goal, we must ensure more equitable geographic distribution of specialist medical training, bolster clinical generalism, emphasise teamwork, and select individuals for further training on the basis of their propensity to serve community needs. We argue that these are the greater challenges for work-readiness and reform.

Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative

The known Managing risk factors for cardiovascular disease (CVD) in patients with diabetes improves their outcomes, but many are not prescribed the recommended treatments. Electronic decision support is a scalable strategy for improving guideline implementation.

The new The implementation of recommended management of CVD risk factors in people with diabetes is incomplete, but better than for patients without diabetes. An electronic decision support tool achieved modest improvements in CVD risk factor screening and treatment escalation in patients with diabetes.

The implications While computerised tools may play an important enabling role, broader strategies are needed to close evidence–practice gaps.

By 2030, diabetes may affect more than 300 million people worldwide.1 Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in patients with type 2 diabetes,2 and large studies have found that managing risk factors for CVD in patients with diabetes reduces both.3,4 According to risk management guidelines, decisions about the need for and the intensity of intervention should be based on the estimated absolute risk.5

A number of guidelines for managing CVD risk in people with diabetes have been published, but studies in Australia6,7 and overseas8–10 have consistently found that these strategies have been only incompletely implemented. Most Australian studies, however, predate a number of targeted quality improvement (QI) programs, including the National Divisions Diabetes, Australian Primary Care Collaboratives, and National Integrated Diabetes Programs, as well as the introduction of targeted incentive payments to general practitioners and practices, and may therefore not accurately reflect current practice. Whether any of these initiatives improved quality of care is unknown.

In this article we describe the contemporary primary care management in Australia of patients with diabetes participating in a study of CVD risk management in primary health care. Our primary objectives were to assess adherence to CVD risk screening and management guidelines, and to determine the effectiveness of a new QI intervention for improving risk management. The main results of the QI study have been published elsewhere;11 we report here a subgroup analysis comparing the outcomes for patients with and without diabetes.

Methods

The Treatment of Cardiovascular Risk in Primary care using Electronic Decision Support (TORPEDO) study was a parallel arm, cluster randomised, controlled trial involving 60 Australian primary health care services (40 general practices and 20 Aboriginal Community Controlled Health Services [ACCHSs]). It assessed whether a QI intervention combining point-of-care electronic decision support with audit and feedback tools improved CVD risk management. The TORPEDO study methods have been described in detail elsewhere.11

Practice eligibility criteria

Health services were eligible to participate if they exclusively used either of the two most common electronic health record systems in Australia for recording risk factor information, pathology test results and prescribed medications. General practices from the Sydney region were recruited between September 2011 and May 2012 through primary health care networks (previously: Medicare Locals), and ACCHSs through two state representative bodies in New South Wales and Queensland.

Patient eligibility criteria

Eligible patients were Aboriginal and Torres Strait Islander people at least 35 years old and non-Indigenous people at least 45 years old (age ranges based on national CVD risk guidelines5) who had attended a participating service at least three times during the preceding 24 months and at least once during the past 6 months. The presence or absence of diabetes was established by a recorded diagnosis of diabetes (type not specified) or a glycosylated haemoglobin (HbA_1c) measurement at baseline of more than 53 mmol/mol. This threshold was chosen as a conservative estimate during the transition period in Australian diagnostic criteria for diabetes, which now recommend a threshold of 48 mmol/mol.

Randomisation

Services were randomised (1:1) to intervention or control groups, stratified at three levels: ACCHSs v mainstream general practices; service size (less than 500 v 500 or more eligible patients); and current participation in a national or state QI program. Permuted block randomisation was performed centrally; outcome analyses were blinded to allocation.

Intervention

Full details of the intervention have been published previously.12 In brief, a screening and management algorithm was developed and validated, based on a synthesis of recommendations from several guidelines (online Appendix 1).13 The algorithm incorporated CVD risk assessment, as well as recommendations for managing CVD, chronic kidney disease, blood pressure (BP) and cholesterol, but not for blood glucose management.

Five-year risk of a cardiovascular event was estimated with the Australian risk calculator, based on the 1991 Anderson Framingham equation.14 High CVD risk is defined in Australian guidelines5 as a calculated 5-year CVD risk of greater than 15%; the presence of diabetes in a person over 60 years old, diabetes together with albuminuria, estimated glomerular filtration rate (eGFR) below 45 mL/min/1.73 m², systolic BP greater than 180 mmHg, diastolic BP greater than 110 mmHg, or total blood cholesterol level over 7.5 mmol/L; or the presence of CVD, defined as a recorded diagnosis of coronary heart disease, cerebrovascular disease (ischaemic stroke or transient ischaemic attack), or peripheral vascular disease. Risk was based on the most recent available results, whether or not the participant was being treated for that risk factor.

The algorithm interfaced directly with the two eligible electronic records systems. Data from the patient record were automatically prepopulated in the tool, and used to generate point-of-care CVD risk management recommendations. A data extraction tool provided site-specific audits, and feedback performance reports were generated. Clinical staff were trained in the application of the tool and had access to a support desk and bi-monthly webinars. The intervention lasted a minimum of 12 months.

Data collection

De-identified data for all patients who met the eligibility criteria were extracted from the clinical database of each health service with a validated data extraction tool.15 The extracts were uploaded to the study database together with an encrypted identifier code.

Outcomes

The primary outcomes for the randomised trial11 were:

The proportion of eligible patients who received appropriate screening for CVD risk factors by the end of the study. This was defined as data for all relevant risk factors having been recorded or updated (smoking status, BP in the past 12 months, total blood cholesterol and high-density lipoprotein (HDL)-cholesterol levels in the past 24 months).
The proportion of patients at high CVD risk at baseline who were receiving recommended medication prescriptions at the end of the study (prescription of at least one BP-lowering drug and a statin for people at high risk without CVD; reduction of CVD risk to below 15% by the end of study; prescription of at least one BP-lowering drug together with a statin and an antiplatelet agent for people with established CVD, unless contraindicated by oral anticoagulant use).

Secondary outcomes included:

the primary outcomes for individuals at high risk who were undertreated at baseline;
measurements of individual CVD risk factors (smoking status, BP, blood lipid levels, body mass index [BMI], eGFR, albuminuria);
escalation of drug prescription for patients at high risk of CVD (either newly prescribed or additional antiplatelet, BP-lowering and lipid-lowering agents); and
BP and serum lipid levels in people at high risk of CVD.

Sample size

Randomisation of 60 services (30 per arm) would provide 90% power to detect an absolute higher occurrence of 10% for each primary study outcome in the intervention arm, assuming a 10% absolute improvement in the control arm, an average cluster size of 750 patients (30% of whom were at high risk of CVD), baseline risk factor measurement and prescribing rates of 50%, α = 0.05 (two-sided), and an intraclass correlation coefficient of 0.05.

Statistical analysis

Post hoc descriptive analyses of baseline data from the TORPEDO study and of data for the cohort of participants present at both baseline and study end were undertaken. Data are presented as means with standard deviations, medians with interquartile ranges, or proportions. Baseline differences between patients with and without diabetes were tested in generalised estimating equations (GEEs) with an exchangeable correlation structure to account for clustering of patients in services.

To determine the predictors of suboptimal drug therapy at baseline, cross-sectional analyses were conducted in a GEE model with logit link function, including both patient level characteristics and service level data. Associations between risk factors and drug therapy were expressed as unadjusted odds ratios (with 95% confidence intervals [CIs]) for binary outcomes.

Intervention effects were analysed by log-binomial GEE regression. The rate ratios of intervention effect were calculated for the individual outcomes at the end of the study. The effects of the intervention in the subgroup of undertreated participants at baseline were analysed in the same model, stratified by diabetes status. An interaction term was included in all models to assess heterogeneity of effects by diabetes status.

Statistical analyses were conducted in SAS Enterprise Guide 5.1 (SAS Institute).

Ethics approval

The study was approved by the University of Sydney Human Research Ethics Committee (HREC) (reference, 2012/2183) and the Aboriginal Health and Medical Research Council of New South Wales HREC (reference, 778/11). Signed agreements with participating sites were obtained. Individual consent waiver was granted because data were collected from de-identified extracts from the electronic health record system.

Results

Recruitment

Sixty-four services were initially recruited; 31 were randomised to the intervention arm (but one withdrew shortly after randomisation) and 30 to usual care (online Appendix 2). Baseline data were extracted for 53 164 patients, including 8829 with diabetes; a cohort of 38 725 (6909 with diabetes) were followed up for outcome evaluation. The median follow-up time was 17 months.

Sample characteristics at baseline

Of the 8829 patients with diabetes at baseline, most had a recorded diagnosis of diabetes (97%); 3% were defined by HbA_1c levels exceeding 53 mmol/mol. The mean age, and the proportions who were men, smokers or Indigenous Australians were higher for people who had diabetes than for those who did not. Their mean systolic BP and blood triglyceride levels were also higher, while their low-density lipoprotein (LDL)- and HDL-cholesterol levels were lower. Albuminuria, renal impairment and an established diagnosis of CVD were more common in people with diabetes (for all differences: P < 0.001; online Appendix 3).

Recording of risk factors and CVD risk at baseline for people with diabetes

Overall, appropriate measurement of CVD risk factors in people with diabetes was greater than for those without diabetes (62.0% v 39.5%; P < 0.001; online Appendix 3), a difference that remained after adjusting for age, sex, and Indigenous status (P < 0.001). BMI was recorded for 81% of people with diabetes, smoking status for 89%, HbA_1c levels for 86%, systolic BP for 94%, albuminuria assessment for 59%, and eGFR for 87%. Recording rates for total, LDL- and HDL-cholesterol levels were 87%, 82% and 79% respectively.

More than one-quarter of patients with diabetes (26%) had established CVD; a further 12%, 4%, and 49% had an estimated 5-year CVD risk that was low (< 10%), medium (10–15%), or high (> 15% or clinically high risk condition present) respectively. There was insufficient information for 825 patients (9%) to categorise their risk (online Appendix 3).

Prescribing rates at baseline for people with diabetes at high risk of CVD

Appropriate prescribing of medications for those identified as being at high risk of CVD was greater among people with diabetes than for those without diabetes (55.5% v 39.6%, P < 0.001; online Appendix 3). Overall, 52.4% of people with diabetes at high risk of CVD but without established CVD and 61.4% of patients with diabetes and established CVD were prescribed recommended medications for averting CVD; the corresponding figures for people without diabetes were lower (22.0% and 49.3% respectively; for each comparison, P < 0.001) (online Appendix 3). The individual medication types prescribed for people with diabetes are shown in Box 1.

Risk factor targets

The HbA_1c levels of 57.3% of patients with diabetes exceeded 53 mmol/mol; about one-quarter of these patients were not prescribed glucose-lowering therapy (Box 2). Similarly, the BP and lipid levels of large proportions of patients with diabetes exceeded recommended target levels (online Appendix 4); of the 61.9% of patients who did not meet the LDL-cholesterol target of 2.0 mmol/L, 44.3% were not prescribed a statin (Box 2).

Predictors of drug prescription

People with diabetes who were older (P < 0.001) or Indigenous (P = 0.030), or had a higher HbA_1c level (P = 0.030), higher systolic BP (P < 0.001), or albuminuria (P < 0.001), were more likely to be prescribed the recommended combination treatment. Conversely, those with higher total cholesterol levels were less likely to receive optimal combination treatment (P < 0.001). Those who did not have a government-reimbursed health assessment (P = 0.012) or care plan (P < 0.001) were also less likely to be prescribed the recommended medications. Service type (general practice v ACCHS) did not influence drug prescription in univariable or multivariable analyses (online Appendix 5).

Effectiveness of the QI intervention

The baseline characteristics of the cohort used for outcome evaluation were similar for the intervention and control groups (online Appendix 3). The intervention was less effective in improving risk factor screening in patients with diabetes than in those without diabetes (P = 0.01). The intervention was only effective in improving rates of prescribing of recommended medications for undertreated individuals at high risk. and was not influenced by diabetes status (P = 0.28). The intervention was associated with intensification of existing antiplatelet, lipid-lowering, and BP-lowering therapy to a similar extent in people with and without diabetes. The intervention did not affect the prescription of glucose-lowering therapy (Box 3).

Discussion

People with diabetes in a contemporary Australian primary care population were more likely to be screened and prescribed the recommended medications for managing CVD risk factors than those without diabetes. The QI intervention was modestly effective in improving screening and treatment levels, but the evidence–practice gaps remained substantial.

Screening deficits were most marked with regard to cholesterol and albuminuria tests, consistent with both overseas16 and local17,18 reports. A recent French study16 found that only half of a group of patients with diabetes had been screened for proteinuria or albuminuria during the previous 12 months, suggesting that renal function is a poorly assessed CVD risk factor. Underprescribing of recommended treatments was striking when the patients with diabetes in our study were stratified by absolute risk: 39% of those with established CVD and 48% of those at high risk of CVD were not prescribed the recommended treatments; almost half of those with diabetes and LDL-cholesterol levels above 2.0 mmol/L were not receiving statin therapy. Similarly, BP targets were not met by half the patients with diabetes, of whom more than one-quarter were not prescribed antihypertensive therapy. These treatment deficits are consistent with international experience,8–10,16 and reflect modest improvements when compared with the findings of previous Australian studies of lipid6,7 and BP7,19 management.

About one-half of people with diabetes did not meet the recommended HbA_1c goal of 53 mmol/mol or less, similar to the 57% figure in the 2003/2004 assessment of the United States National Health and Nutrition Examination Survey (NHANES) participants.20 It is worrying that about one-quarter of our patients with HbA_1c levels over 69 mmol/mol were not prescribed glucose-lowering medication, a proportion substantially larger than the 3% of patients with HbA_1c levels of 53 mmol/mol or more not treated in a recent Canadian study.10 Our findings may be partly explained by patient preference for non-pharmacological treatment, and by relaxed glycaemic targets in certain populations (older people, and people with frequent hypoglycaemia or hypoglycaemic unawareness).

Our findings suggest that undertreatment has diminished to some degree since 2002, which may reflect the effect of incentive schemes and quality of care initiatives. The deficits that remain may be explained by the proliferation of guidelines with differing perspectives, and time-pressured consultations with patients presenting with several complaints. Patients with diabetes who had a formal care plan, enabling coordination of their management with other health care providers, were more likely to be treated as recommended. However, causal inferences cannot be made, as numerous factors may confound this association.

The finding that CVD risk screening and management at baseline was better for those with diabetes than for people without diabetes is consistent with other reports,21,22 and may explain why the effect of the intervention was less marked in these patients. Although it was not effective in improving the overall level of new prescriptions for individuals at higher risk of CVD, the intervention was associated with improvements for people who were not receiving recommended treatments at baseline, regardless of their diabetes status. This is important in light of suggestions that therapeutic inertia may be a greater contributor to lost therapeutic benefit in patients with diabetes than lack of treatment.23

There is evidence that patient-directed interventions combined with physician-focused strategies may be more effective than the latter alone.24 Successful elements of collaborative care programs for improving chronic disease management include evidence-based guidelines, systematic screening and monitoring of risk factors, scheduled recall visits, new or adjusted roles for team members, information support for the clinician, enhanced self-management by the patient, effective communication between all members of the care team, and audit information for the practice.25 New policy proposals, such as “Health Care Homes”,26 and a renewed focus on initiatives such as “My Health Record” incorporate some of these elements.

Study limitations

Many of the sites in our study were teaching practices; this may explain why performance was higher than reported in previous studies. However, the recruited services were reasonably representative of Australian general practice with respect to the use of information technology.27 The ACCHSs recruited were geographically diverse and had similar service characteristics to the sector as a whole.28

The National Vascular Disease Prevention Alliance (NVDPA) guidelines5 recommend incorporating pre-treatment risk factor levels when assessing CVD risk. As pre-treatment data were not available, we analysed the patients’ most recent BP and lipid data, regardless of treatment status, and this may have led to underestimating risk for some individuals. However, as 72% of patients with diabetes were at high risk regardless of their risk score (online Appendix 3), this was probably not a major problem.

We regarded 2 years as an appropriate interval between lipid measurements, rather than varying the interval according to risk status as recommended by NVDPA guidelines. This may not have been appropriate for individuals at high risk, for whom more frequent testing is recommended. Conversely, the Royal Australian College of General Practitioners guidelines recommend 5-yearly lipid measurements for people at low risk;29 if doctors are adhering to these recommendations, the frequency of assessment may be adequate, but with a median follow-up period of 17 months we were not able to assess whether this was the case. If biases were introduced by using different lipid measurement intervals, we would expect them to be the same for the intervention and control arms.

Other limitations included the fact that that the type of diabetes was not specified, and that relying on electronic records data precluded assessing the role of clinical judgement in treatment decisions.

Conclusion

Although recommendations for managing CVD risk were more frequently implemented for people with diabetes than for those without diabetes, evidence–practice gaps remain. While the evaluated intervention was moderately effective in improving screening of risk factors, additional strategies are needed if Australia is to meet targets of reducing mortality for CVD and diabetes by 25% over the next 10 years.30

Box 1 –
Rates of prescribing of currently recommended cardiovascular disease risk-factor-specific medications for patients with diabetes

* For patients with HbA_1c levels above 53 mmol/mol.

Box 2 –
Patients with diabetes with values above targets at baseline, and number who did not receive the corresponding recommended treatment

Patients with elevated level

Number not treated to reduce level

HbA_1c level

> 53 mmol/mol

4329 of 7556 (57.3%)

1038 (24.0%)

> 69 mmol/mol

1822 of 7556 (24.1%)

450 (24.7%)

Blood pressure (BP)

Systolic BP > 130 mmHg or diastolic BP > 80 mmHg

4835 of 8329 (58.1%)

1354 (28.0%)

LDL-cholesterol level

> 2.0 mmol/L

4339 of 7007 (61.9%)

1922 (44.3%)

> 2.5 mmol/L

2769 of 7007 (39.5%)

1412 (51.0%)

HbA_1c = glycated haemoglobin; LDL = low-density lipoprotein.

Box 3 –
Effects of the quality improvement intervention in patients with and without diabetes

Intervention

Usual care

Rate ratio

95% CI

Receiving appropriate screening

12 164/19 385 (62.8%)

10 317/19 340 (53.4%)

1.25

(1.04–1.50)

0.01

With diabetes

2738/3617 (75.7%)

2323/3292 (70.6%)

1.14

(1.00–1.30)

Without diabetes

9426/15 768 (59.8%)

7994/16 048 (49.8%)

1.28

(1.04–1.58)

Receiving appropriate screening (undertreated at baseline)

3773/9276 (40.7%)

3532/10 782 (32.8%)

1.38

(1.10–1.73)

< 0.01

With diabetes

559/1160 (48.2%)

507/1151 (44.0%)

1.28

(1.00–1.63)

Without diabetes

3214/8116 (39.6%)

3025/9631 (31.4%)

1.40

(1.11–1.78)

Patients at high risk of cardiovascular disease

Receiving appropriate prescriptions

3030/5335 (56.8%)

2483/4846 (51.2%)

1.11

(0.97–1.27)

0.10

With diabetes

1700/2679 (63.5%)

1458/2495 (58.4%)

1.06

(0.93–1.21)

Without diabetes

1330/2656 (50.1%)

1025/2351 (43.6%)

1.18

(1.03–1.36)

Receiving appropriate prescriptions (undertreated at baseline)

1085/2827 (38.4%)

472/2263 (20.9%)

1.59

(1.19–2.13)

0.28

With diabetes

553/1269 (43.6%)

178/923 (19.3%)

1.63

(1.11–2.38)

Without diabetes

532/1558 (34.2%)

294/1340 (21.9%)

1.53

(1.16–2.01)

Increased antiplatelet therapy^†

470/2638 (17.8%)

65/2424 (2.7%)

4.79

(2.47–9.29)

0.08

With diabetes

210/908 (23.1%)

20/829 (2.4%)

7.28

(3.34–15.9)

Without diabetes

260/1730 (15.0%)

45/1595 (2.8%)

4.05

(2.03–8.08)

Increased lipid-lowering therapy^†

1026/5335 (19.2%)

226/4846 (4.7%)

3.22

(1.77–5.88)

0.84

With diabetes

608/2679 (22.7%)

130/2495 (5.2%)

3.32

(1.74–6.33)

Without diabetes

418/2656 (15.7%)

96/2351 (4.1%)

3.22

(1.77–5.86)

Increased blood pressure-lowering therapy^†

1243/5335 (23.3%)

586/4846 (12.1%)

1.89

(1.09–3.28)

0.54

With diabetes

729/2679 (27.2%)

316/2495 (12.7%)

1.91

(1.09–3.35)

Without diabetes

514/2656 (19.4%)

270/2351 (11.5%)

1.96

(1.10–3.47)

Patients with HbA_1clevels > 53 mmol/mol at baseline

Appropriate glucose-lowering drug

1111/1269 (87.6%)

955/1118 (85.4%)

1.02

(0.95–1.11)

Increased glucose-lowering therapy

711/2679 (26.5%)

304/2495 (12.2%)

1.75

(0.95–3.22)

* Patients with diabetes v patients without diabetes. † For patients not meeting recommended targets for corresponding parameters (online Appendix 4).

Federal money announced for doctors’ mental health

Health Minister Greg Hunt will work directly with doctors to develop a mental health care package for the medical profession.

Addressing the AMA National Conference on May 26, Mr Hunt (pictured) said a recent spate of young doctor suicides – including that of Deputy Chair of the AMA Doctors-in-Training Council Dr Chloe Abbott – has been a cause for great concern.

The Minister said that after speaking with AMA President Dr Michael Gannon and former President Dr Mukesh Haikerwal, he was determined to develop a mental health package targeting doctors.

“One of the main things we introduced in the Budget was prioritising mental health. For the first time, this has been raised to the top level as one of the four pillars of the long-term national health Plan,” Mr Hunt said.

“And we were able to invest significantly in mental health, both in the election, but in particular, in the Budget as well. There’s a very strong focus on suicide prevention with support for suicide prevention hotspots and an $11 million initiative, but also complementing that with the rural telehealth initiative for psychological services.

“Much of this is deeply important preventive health work on the mental health side and it goes with what has to happen in, I think, the medical work force. The case of Chloe Abbott was outlined and I’m aware that many people have been affected by Chloe’s loss, as well as others.

“And Michael and I have been speaking this week, and also been speaking in recent weeks with Mukesh Haikerwal, and I am determined to offer a partnership with the Government and the AMA for us to provide new investment directly into caring for carers.

“And so I want to announce that we will offer a partnership going forward and we will develop the suicide prevention, mental health programs with the AMA and the broader medical work force for suicide prevention and mental health support, specifically for doctors and other medical work force professionals.

“One of the critical roles that you have is psycho-social services. There’s the clinical work with those with mental health issues, but then there is the support services.”

The Minister offered few details of the partnership, stressing that it was still in its conception stage.

But he was determined to take action.

Following his address to the conference, he spoke more to the media about the plan.

“There have been some terrible tragedies in the sector. Michael Gannon and other doctors, Mukesh Haikerwal, have talked to me about that,” he said.

“What we’ll be doing is developing a caring for carers package which will be assisting with specialist channels, because sometimes, and this is what’s been explained to me, those who are doctors or nurses (a) will feel that they shouldn’t be seeking help even though they’re just the same as everybody, and (b) they might feel professionally uncomfortable. Even though they might be in the depths of despair they’ll still feel that professional discomfort at reaching out.

“And so if they have some specialised services for them then they will feel more comfortable, we hope, and that’s what’s been proposed by the profession.”

He did not know if the plan would address the mandatory reporting lines, where doctors might fear they would be reported to the Medical Board when they seek help.

He also promised funds to the partnership, but could not say how much at this stage.

“There’s been no proposal put to me yet, but as I’ve said, in designing of this, what I really want to do is work with the AMA and the GPs,” he said.

“What we’re doing is we’re designing together, and from that we’ll have the outcome.”

This article was originally published in Australian Medicine. Read the original piece here.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

What needs to happen to build resilience and improve mental health among junior doctors

Doctors experience higher levels of suicide and mental distress than their non-medical peers. A review of studies in the area found male doctors had a 26% higher risk of suicide, while female doctors had a 146% higher risk (more than double) than the general population.

And a recent survey, conducted by the mental health foundation beyondblue, confirmed there were higher rates of suicidal thoughts and psychological distress among doctors and medical students than in the general community.

But beyond the numbers are tragic stories of young individuals who lost their lives to suicide. In recent months, the suicide of four junior doctors in New South Wales has prompted the state government to investigate the issue. News reports have suggested at least 20 doctors took their own lives between 2007 and 2016 in NSW.

Family members have pointed to stress, “brutal expectations” and working hours as having had an impact on the doctors’ decisions to end their lives.

Are our medical students and junior doctors overworking? Can we identify underlying causes of mental distress and suicidal thoughts, as well as the warning signs? Can medical schools, hospital employers, supervisors, professional organisations and peers do more to prevent further tragedies?

A host of factors

Various inquiries and reviews have considered the above questions, in Australia and overseas. The conclusion is that it’s complex. Behind the phenomenon are a number of interacting factors.

There’s a legacy professional culture that can still view any admission of psychological distress as weakness or incompetence.

Doctors face long work hours in a pressured work environment. They experience anxiety about making mistakes that can have serious consequences.

Workplace bullying and harassment can also contribute. While this has most recently been highlighted among trainee surgeons, it probably extends well beyond surgical training.

And of course doctors have technical knowledge and access to the means to end life.

A lot has already been done to try to improve doctors’ mental health. For instance, progress has been made to reduce working hours. Prolonged shifts and continuous on-call rosters have been discontinued in most, if not all, health service rosters. This was at least in part in response to pressure from the Australian Medical Association (AMA) Safe Hours campaign, which outlined the risks to patients and practitioners of excessive hours worked and the need for breaks between shifts.

These recommendations have been incorporated into industrial agreements for hospital medical staff. These stipulate maximum working hours and mandatory periods of time off. However, 14-hour shifts and rosters that include one in three or four weekends without any reduction in weekday hours are not uncommon. There is considerable anecdotal evidence that some junior doctors are working more hours than they are rostered for.

Progress has been made in other areas too. Polices for better orientation of junior doctors in hospitals to explain supervision and avenues for support have been implemented. Other measures adopted include: education and mentoring programs in hospitals; supervisor training; blame-free reporting; assessment by external accreditors of health services’ and specialty colleges’ reporting and support arrangements; mental health first aid training for students; medical student guides; and confidential doctors’ health services.

But introduction of these initiatives has been patchy. The levels of support available in different hospitals are variable, and too often dependent on a few enthusiastic individuals. A systematic national approach would have much greater impact.

Medical graduates

One source of increasing stress for recent graduates, anecdotally, is the intense competition to get a job that will be their pathway to a specialist qualification. This pressure has its genesis in the dramatic boost to medical graduate numbers over the past 15 years.

Training beyond medical school is an intense period of four to nine years of work, on-the-job learning, study and examinations. By doubling the number of medical schools and almost tripling the number of medical graduates, Australia has severely increased competition in capital-city teaching hospitals (where, unfortunately, most of the training jobs for medical graduates remain based).

Ironically, the main reason for the boost in graduate numbers was the shortage of doctors in regional areas. An increasing number of young doctors (including those who trained in rural clinical schools or regional medical schools) feel that they have little choice but to apply for accredited metropolitan training posts.

They would be better off working and training from a home base in regional Australia, if only the specialist training pathways existed. Australia desperately needs to re-align this phase of medical training to better serve both regional communities and graduates.

Building resilience

There are core professional capabilities that should be taught and modelled throughout medical training. These include managing one’s own health needs, dealing with stress and fatigue, recognising and assisting distressed colleagues, and reporting bullying and harassment.

Medical schools and hospital employers could do better in finding ways to communicate with one other to protect more vulnerable graduates as they transition into the workforce.

We should also critically review our approaches to selecting students into medical school. Selection policies that promote greater diversity, place more emphasis on humanistic qualities (qualities that define who we are as human beings such as honesty, integrity, courage, self-awareness and wholeheartedness) rather than examination marks, and that include people with a positive orientation to risk and innovation may help to take the steam out of the pressure cooker. These approaches could also improve workforce outcomes in rural and under-served communities.

Beyond “resilience building”, there are important system challenges in how the nature of healthcare needs to be transformed into something that is more integrated, person-centred and community-based. This has particular implications for our larger institutions.

It turns out that finding “joy and meaning” in healthcare work is not only good for doctor well-being, it’s also safer for our patients. Teamwork, fun and personal fulfilment in caring for others are the essence of the joy of medicine.

If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 44.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

Richard Murray, Dean of Medicine & Dentistry, James Cook University and Brendan Crotty, Professor & Executive Dean, Faculty of Health, Deakin University

This article was originally published on The Conversation. Read the original article.

Six keys for managing work fatigue

Workplace fatigue is a huge issue in healthcare, putting both doctors and their patients at considerable risk. The evidence in the published literature is clear about the dangers of working long hours: one study has shown that a person working 17 hours or more has the abilities equivalent to someone with a blood-alcohol reading of 0.05. Another found that doctors working 24-hour shifts were around one-third more likely to commit a serious medical error.

That finding was replicated in a trial that randomised junior doctors working in intensive care to their usual 24-hour-plus shifts, or to shifts without extended hours. Those who didn’t have to work the long shifts made 22% fewer errors.

While patients obviously suffer from such errors and poor decision-making, constant fatigue can also put an intolerable strain on doctors: in the long term it can lead to depression, anxiety, heart disease or diabetes.

Then there’s the medico-legal angle. Doctors may be subject to complaint or discipline in cases where a patient is harmed due to errors linked to fatigue. For example, in one recent case conditions were placed on a junior doctor’s registration after a child died due to deficient treatment. The harmful treatment happened when the doctor was in the 20^th hour of a 24-hour shift.

At the same time, doctors often feel under huge pressure to continue working even when they know that fatigue may be clouding their judgement. In the case of understaffed hospitals, doctors may consider it simply unethical to walk away from patients in need.

They are also less likely to seek medical help than the rest of the population are less likely to have a GP, and are more likely to self-medicate and self-diagnose.

Here are some tips for doctors to better manage their fatigue at work:

Complete the AMA’s online safe hours audit. It takes around 10 minutes, can be done anonymously, and generates an instant risk assessment report;
Make sure you have a good sleep environment, free of screens and technology;
Managing fatigue means managing lifestyle factors, including regular exercise and moderation in alcohol consumption;
While at work, make sure you keep yourself well-hydrated, and take regular short naps throughout a long shift;
See your GP for advice before fatigue becomes a problem;
Contact your local Doctors’ Health Advisory Service for support and advice.

Source: Avant

For more information about managing fatigue and other health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

What links anxiety, depression and insomnia

Good sleep is essential for our mental well-being. Just one night of disturbed sleep can leave us feeling cranky, flat, worried, or sad the next day. So it’s no surprise sleeping problems, like difficulty falling asleep, not getting enough sleep, or regularly disrupted sleep patterns, are associated with anxiety and depression.

Anxiety and depression, which can range from persistent worry and sadness to a diagnosed mental illness, are common and harmful.

Understanding the many interacting factors likely to cause and maintain these experiences is important, especially for developing effective prevention and treatment interventions. And there is growing recognition sleep problems may be a key factor.

Which problem comes first?

The majority of evidence suggests the relationship between sleep problems and anxiety and depression is strong and goes both ways.

This means sleep problems can lead to anxiety and depression, and vice versa. For example, worrying and feeling tense during bedtime can make it difficult to fall asleep, but having trouble falling asleep, and in turn not getting enough sleep, can also result in more anxiety.

Sleep disturbance, particularly insomnia, has been shown to follow anxiety and precede depression in some people, but it is also a common symptom of both disorders.

Trying to tease apart which problem comes first, in whom, and under what circumstances, is difficult. It may depend on when in life the problems occur. Emerging evidence shows sleep problems in adolescence might predict depression (and not the other way around). However, this pattern is not as strong in adults.

The specific type of sleep problem occurring may be of importance. For example, anxiety but not depression has been shown to predict excessive daytime sleepiness. Depression and anxiety also commonly occur together, which complicates the relationship.

Although the exact mechanisms that govern the sleep, anxiety and depression link are unclear, there is overlap in some of the underlying processes that are more generally related to sleep and emotions.

Some aspects of sleep, like the variability of a person’s sleep patterns and their impact on functioning and health, are still relatively unexplored. More research could help further our understanding of these mechanisms.

Sleep interventions

Disentangling which problems come first, and under what circumstances, is difficult.
masha krasnova shabaeva/Flickr, CC BY

The good news is we have effective interventions for many sleep problems, like cognitive behaviour therapy for insomnia (CBT-I).

So there is the possibility that targeting sleep problems in people who are at risk of experiencing them – like teenagers, new mothers and people at risk for anxiety – will not only improve sleep but also lower their risk of developing anxiety and depression.

Online interventions have the potential to increase cost-effectiveness and accessibility of sleep programs. A recent study found a six-week online CBT-I program significantly improved both insomnia and depression symptoms. The program included sleep education and improving sleep thoughts and behaviours, and participants kept sleep diaries so they could receive feedback specific to their sleep patterns.

We’re conducting some research to improve and even prevent physical and mental health problems early in life by targeting sleep problems. Using smart phone and activity tracker technology will also help tailor mental health interventions in the future.

General improvements to sleep might be beneficial for a person with anxiety, depression, or both. Targeting one or more features common to two or more mental disorders, like sleep disturbance, is known as a “transdiagnostic” approach.

Interventions that target transdiagnostic risk factors for anxiety and depression, like excessive rumination, have already shown some success.

A good foundation

For many people, treating sleep problems before treating symptoms of anxiety and depression is less stigmatising and might encourage people to seek further help. Addressing sleep first can develop a good foundation for further treatment.

For example, people with a depressive disorder are less likely to respond to treatment and more likely to relapse if they have a sleep problem like insomnia.

Many of the skills learned in a sleep intervention, such as techniques for relaxation and reducing worry, can also be used to help with daytime symptoms of both anxiety and depression. And this is not to mention the physical benefits of getting a good night’s sleep!

If you’re concerned about your sleep or mental health, speak to a health care professional such as your GP. There are already a number of effective treatments for sleeping problems, depression and anxiety, and when one is treated, the other is likely to improve.

And with research in this area expanding, it’s only a matter of time before we find more ways to use sleep improvement interventions as a key tool to enhance our mental health.

Professor Emeritus John Trinder contributed to this article.

Joanna Waloszek, Postdoctoral Research Fellow in Psychology, University of Melbourne and Monika Raniti, Master of Psychology (Clinical)/PhD Candidate, University of Melbourne

This article was originally published on The Conversation. Read the original article.

The one thing that helps in chronic disease

Exercise, exercise and more exercise should be recommended to people with non-communicable chronic diseases, say Finnish researchers.

And it doesn’t necessarily matter what kind of exercise, or even what kind of chronic disease the patient has, according to a new umbrella review of 85 meta-analyses.

Aerobic exercise, resistance training, or a combination of both all improved functional capacity in roughly equal measure across 22 common chronic diseases, in randomised trials comparing exercise therapy with no treatment or usual care.

Chronic diseases in the review included osteoarthritis, rheumatoid arthritis, coronary artery disease, heart failure, type 2 diabetes, various cancers and Alzheimer’s disease.

The review encompassed 146 physical and functional capacity indicators, such as the six-minute walking test, maximal lower body muscle strength, balance tests and self-assessed ability to carry out everyday functions. Around 85% of these indicators were improved with exercise, with 20% showing large improvement.

These improvements were similar in both objective performance measurements and patients’ own assessment of their function.

At the same time, reported adverse events were no greater in exercise versus control groups.

The study authors from the University of Jvaskyla say research into exercise in chronic conditions has generally been more focused on risk factors, prevention and risk of death, and has often overlooked the importance of physical functioning.

Better function improves coping with daily living and may lessen pain and even disease progression, the researchers say. On a societal level, there are also economic benefits in reducing care needs of people with chronic conditions and improving their ability to live at home.

The authors suggest exercise therapy should be recommended to all patients with non-communicable chronic diseases, although training programs should be progressive and include follow-ups to monitor adherence, effectiveness or any adverse effects.

You can read the study here.

Doctor burnout: a worldwide epidemic

Burnout is the modern day pandemic affecting the medical profession. It is a condition which leaves many of us in denial. After all, it can’t be seen on a biopsy result or under an electron microscope, so how real can it be?

Very real.

Up to 59% of doctors are burnt out, according to a 2017 Medscape report. Some studies report burnout rates of up to 65% in some specialty groups, and the rates of burnout have increased over the last 10 years. It would be unlikely to consider that this is simply because there is greater awareness of the condition.

50% of medical students and 70% of junior doctors are burnt out.

This is staggering, and these results are across the board globally. Not just the USA and not just UK. These are overall global professional rates of burnout and the rates are deeply alarming.

Even if we had 30% of the profession suffering from burnout, this would still be a pandemic, yet there is not the global attention to this matter that it deserves.

If there was an outbreak of influenza or a critical disease globally that was wiping out even 5% of people and removing them from the work force, there would be a worldwide inquiry.

Yet here we have matters where there are up to 65% rates of burnout, over half of the entire medical profession, including students, and there is no worldwide inquiry into what is going on in medicine.

Certainly there is no vaccine likely to be available, but the matter is critical.

Ought not the World Health Organisation be taking a key interest in this matter?

The WHO has released a report stating that there is a worldwide epidemic of chronic non communicable diseases, yet there is no report stating that there is a worldwide epidemic of high level dysfunction in our doctors, the very people who are caring for those with illness and disease.

The health of our global population is clearly in crisis with increasing rates of illness and disease to the extent that the WHO has said there is a worldwide epidemic of chronic non-communicable diseases.

We need healthy health care providers to lead the way

If our health care providers are in a state of ill health, which is what burnout is, then we have an even bigger crisis on our hands.

These rates of burnout show that the medical profession is in crisis, and with it our global future health care is in crisis, at a time when we need healthy healthcare providers more than ever.

Burnout is not a simple matter of being a little bit tired. It is associated with higher rates of:

Depression
Anxiety
Fatigue – both physical and emotional
Increased risk of medical errors
Decreased rates of patient satisfaction,
Causes people to leave the medical profession
Higher rates of suicidal thoughts and increased risk of suicide (in a profession where the rate of suicide is already at least 2 times higher than the general population with some studies reporting up to 5.7 times higher rates)
Higher rates of cardiovascular disease and musculoskeletal pain
Deep professional unhappiness and cynicism
De-personalisation and decreased understanding and compassion

Neither of which are features desirable or sustainable in someone who is dealing with people in situations that are incredibly trying.

Burnout is not something that is random affecting a few ‘sensitive’ people with ‘poor coping skills’. It quite specifically affects over half of the medical profession, people who specifically enter a profession because they are dedicated to caring for others.

We need to stop and ask not only why, but how.

Are we to blame the ‘nature of the person’ choosing to do medicine, and blame them for simply ‘not coping’? Or perhaps rather is it time to take a wider look at the global culture of medicine that fails to nurture the people that do medicine?

Being in a war zone and in the armed forces is highly stressful, as I am sure that we would all agree and understand. Yet people who have been in the army and in a war zone report that medicine is far more stressful. This does not make sense given that we say that we are a caring profession that values and cares for people.

I have heard people formerly in the army say they were more cared for as people in the army and given greater respect and compassion as people than they have been in medicine.

It is clear that there is a big issue here.

Doctors are people too. If we are to be true to medicine and its foundations of care for all people, then we must equally care for the health and well-being of those who are doing their best to care for others, those within the profession.

Literally over half of our medical profession is burnt out. This is not simply a matter of a few people being a bit tired from too much work to be decried for ‘not coping’. This is an institutionalised issue, a worldwide crisis and one that global attention needs to be paid to.

Dr Maxine Szramka is a Sydney-based rheumatologist and Clinical Senior Lecturer at the University of Wollongong. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

For further support and information, call Lifeline on 13 11 14